A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?

BMI of 20

Peripheral neuropathy

Immobility

Hypoperfusion

Prealbumin level of 16 mg/dL

Answer and Explanation

Correct Answer : B,C,D,E

A. BMI of 20:
A BMI of 20 is within the normal range. While extremes of BMI, either low or high, can contribute to health issues, a BMI of 20 alone may not significantly increase the risk of pressure injuries.

B. Peripheral neuropathy:
Peripheral neuropathy, which involves damage to the nerves in the extremities, can lead to decreased sensation and awareness. Clients with peripheral neuropathy may have difficulty sensing pressure, friction, or discomfort, making them more susceptible to pressure injuries.

C. Immobility:
Immobility is a significant risk factor for pressure injuries. Clients who are unable to change positions frequently are more likely to develop pressure points, particularly over bony prominences. Regular repositioning is essential to prevent pressure injuries in immobile individuals.

D. Hypoperfusion:
Hypoperfusion, or inadequate blood flow to tissues, can compromise tissue viability. Proper blood circulation is crucial for delivering oxygen and nutrients to the skin and underlying tissues. Impaired perfusion can contribute to tissue damage and increase the risk of pressure injuries.

E. Prealbumin level of 16 mg/dL:
Prealbumin is a marker of nutritional status. A low prealbumin level (16 mg/dL) indicates malnutrition, which can impair the body's ability to repair and maintain tissues, including the skin. Malnourished individuals are at an increased risk of developing pressure injuries.

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Correct Answer is C

Explanation

A. "I will allow the position my mother finds most comfortable during the feeding."
This statement does not provide specific guidance on the proper positioning for enteral feedings. It's important to follow recommended positions to prevent complications.

B. "I will turn my mother on her left side during the feeding."
Turning the client on the left side is not a recommended position for enteral feedings. The head of the bed is usually elevated to 30-45 degrees to prevent aspiration.

C. "I will position the head of the bed 45 degrees during the feeding."
This is the correct choice. Elevating the head of the bed to 45 degrees helps prevent aspiration and facilitates proper flow of enteral feedings into the stomach.

D. "I will elevate the head of the bed 10 degrees during the feeding."
While some elevation is better than lying flat, the recommended angle is usually 30-45 degrees to minimize the risk of regurgitation and aspiration.

A. Explain alternatives to the procedure to the client. B. Discuss the risks of the procedure with the client. C. Confirm that the client is competent to sign for the procedure. D. Inform the client about what will occur during the procedure.

Correct Answer is C

Explanation

A. Explain alternatives to the procedure to the client.
The nurse should provide information about alternative treatments or procedures available to the client, ensuring they have a comprehensive understanding of their options.

B. Discuss the risks of the procedure with the client.
It is crucial for the nurse to communicate the potential risks and complications associated with the procedure to the client, allowing them to make an informed decision.

C. Confirm that the client is competent to sign for the procedure.
Before obtaining informed consent, the nurse should ensure that the client has the mental capacity to understand the information provided, make decisions, and provide consent.

D. Inform the client about what will occur during the procedure.
The nurse should educate the client about the details of the procedure, including what to expect before, during, and after. This information aids in the client's understanding and decision-making process.

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A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?

Nursing Test Bank

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